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First Name |
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Last Name |
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Address |
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City, State |
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Native State |
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Country |
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Email |
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Phone |
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May we call you at this number? |
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Date of birth |
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Height |
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Weight |
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Eye Color |
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Hair Color |
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Skin Color |
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Religion |
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Employed? |
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Profession |
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Education Level Completed |
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College(s) Attended |
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How did you hear about us? |
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Are you able to make 6-12 months commitment to the program? |
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Family and Medical Information |
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Biological Father's Ethnicity/Religion/Country of origin |
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Biological Mother's Ethnicity/Religion/Country of origin |
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Are you in touch with both biological parents? |
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Have you lived in the UK or Europe for longer than 3 months from 1980 to the
present? |
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Have you had any tattoos or body piercings done in the past year? |
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Have you or anyone in your biological family including uncles, aunts
and grandparents, ever had the following:
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Mental illness, including bipolar disorder, schizophrenia or depression |
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Genetic diseases, including Alzheimer's, sickle cell, diabetes, heart ailments etc. |
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Birth defects, including spina bifida, cleft palate, malformed heart or other
organs |
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Do you have any mouth lesions, sores, or blisters. Any genital ulcers, sores, or
warts. Any urethral discharge? |
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Alcoholism or substance abuse |
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Do you drink alcohol?
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If so, how many drinks per week? |
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Do you smoke?
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If so, how many cigarettes a day? |
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Marital status? |
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Your sex partners in the last five years |
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Other comments |
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